Expand Medicare to Include Dentalcare

While Canada’s medicare system was launched in the 1960s, some notable exclusions remain. Vision, pharmaceuticals, mental health, and dental care are all aspects of health that remain largely uncovered by our public health system. Brandon Doucet, dentist and member of the Coalition for Dentalcare, and Thomas Lange, health economist and research coordinator at the University of Calgary, join Team Advantage to discuss the potential ways health coverage could be expanded to include dentalcare.

Follow the Coalition for Dentalcare on Twitter @for_dentalcare, and follow Tom Lange @TomLangeYYC.

Read Brandon’s piece in Passage on the topic here:

Read Tom’s research papers here:

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Kate: Hello, and welcome to The Alberta Advantage. I’m your host, Kate Jacobson, and joining Team Advantage today are Karen —

Karen: Hello.

Kate: Patrick —

Patrick: Hello.

Kate: And special guests Brandon Doucet, dentist and member of the Coalition for Dentalcare, and Thomas Lange, health economist and research coordinator at the University of Calgary’s School for Public Policy. Brandon and Thomas, thank you for joining us here on the podcast.

Brandon: Thanks for having us.

Thomas: My pleasure.

Kate: Canadians are, in general, pretty proud of our medicare problem and, despite strenuous efforts over the decades to privatize portions of it by some governments, it does remain a very important part of Canadian society, but it also has some quite curious limitations. If you break pretty much any bone in your body, you can go to a hospital and have it taken care of through our public medicare system, but the bones in your mouth are currently very special exceptions to this rule. Mouth bones — or teeth, as we more commonly refer to them — are not included in Canada’s medicare coverage; unless, of course, something goes so horribly wrong with your teeth that it starts to impact other aspects of your health or your health in other parts of your body. My understanding is that most people in Canada access dental care primarily through work-related insurance. How do those without work-related coverage access dental care in this country?

Thomas: That’s a great question. As you mentioned, dental care was not included in our universal healthcare system, so people do primarily rely on work-related dental insurance in order to access care. For people who don’t have work-related dental insurance, they have to pay for these services either out of pocket or, if they’re lucky enough to be eligible for a targeted government program, which are very few and far between; so, if we actually break down dental spending in Canada, what we find is that 95% of that spending goes to either work-related insurance or out-of-pocket payments. The overwhelming majority is in the private sector, and only a meager 5% in on government programs. This is an even lower percentage of government dental spending than even the Americans.

Brandon: The Canadian Community Health Survey has pointed out that about 60% of Canadians have some kind of insurance plan for dental. Most of that is, as you said, employer-based — that’s about 60% of those that have it — and then the rest is: either they purchased their own plan, like as a home family unit, or they do not have insurance.

Kate: As you’re probably aware, our economy continues to basically shed full-time jobs with benefits and then replace those jobs with part-time and precarious gig work. What do these changes in the labour market mean for working people and how working people might access dental care?

Brandon: This results in more Canadians not having dental insurance tied to their labour because their work doesn’t provide benefits like dental insurance. This is a trend that we’ve been seeing for many years, now. When we talk about, for example, over one in three Canadians lack dental insurance and one in five Canadians avoid the dentist each year because of financial constraints, these are numbers that are actually rising because of these changes in the nature of work; because of younger people working in the gig economy more, but also because there’s large numbers of older people who are retiring and losing their benefits, as well.

Patrick: What happens, then, when people lose their dental coverage? People without coverage are still going to have fillings that they need done, dental pain — where do they go to get help when they need dental care? What tends to happen, especially for people who really can’t afford the out-of-pocket costs?

Brandon: What happens a lot of the time, when people have no dental insurance, is: they have to scrounge up the money. There’s very limited public programs that cover people who don’t have dental insurance and, oftentimes, even people who have those, who are covered under those programs, struggle to find a dentist who will accept the low fees paid out by those programs or, because the program pays out a low amount, they’re billed the extra amount that the dentist would normally charge, which kind of precludes these people from accessing dental care. So, what happens for a lot of these people is: they need to ration funds, they need to put money towards pain and infection and neglect small problems. So, they don’t go in for cleanings because they need to focus money on extractions. They don’t get small cavities filled because they need to focus on pain and infection, but what happens, because this is the case, those small problems grow and become larger. This results in a lot of pain and suffering from the population and, also, lowering the quality of life for people.

Thomas: Yeah. If you suddenly become unemployed, you need to prove to the government that you are eligible for these programs, so you need to prove that you have become impoverished because these programs are typically only geared to those who can receive social assistance and other welfare supports. The problem is that requires your notice of assessment from a previous tax cycle more often than not; it’s not enough to simply say, “I’m now on EI, so can I go on this benefit?” There’s actually quite a bit of red tape and navigating of the system you have to do.

Karen: Similar to that — teeth that appear shiny, bright and white are often a kind of class marker which can be useful for things like networking and getting a job in the right circles. What consequences does the unequal distribution of dental care in our country have for social mobility and people’s ability to pursue new opportunities?

Brandon: I think that’s a great point that you just made, because I think many people can sympathize with the idea of: if you have visible decay or missing front teeth, it would be very difficult to find a good-paying job because of that social aspect, and that really locks people in that cycle of poverty. It’s so hard to break out of that cycle and, as we’ve mentioned, those problems only compound and get worse. It’s a really devastating cycle from the purely economic standpoint. There’s also many other health-related aspects as well, because you can imagine how difficult it is to sleep when you have a toothache. There’s also many general health conditions that actually are either caused or worsened by poor oral health. I have a list of them here, and I think it’s really telling, so: there’s diseases like cardiovascular disease, diabetes, having a low birth weight infant, aspiration pneumonia, erectile dysfunction, osteoporosis, metabolic syndrome, and stroke. So, people who can’t afford dental care, they’re destined to have those consequences because they can’t afford care.

Kate: Because dental care is so difficult to obtain for so many people, there’s basically an incentive to only do dental work that is absolutely necessary or to wait until things are too bad or too painful to ignore, like you mentioned. This flies in the face of basically what we know about effective medicine, namely that preventative and early care results in better outcomes for people’s health. This was a point that was really brought up a lot in the lead-up to the implementation of medicare. Could you outline, a bit, some of the consequences of this “bare minimum when necessary” approach to dental care?

Brandon: Some of the consequences to this “bare minimum” approach is that people have to live with chronic dental pain, they have to live with missing front teeth and visible decay for many years until it becomes too painful to handle. So, there’s many social and economic consequences — that’s to the individual, but there’s also costs towards society as a whole. When people have poor oral health, as we’ve already mentioned, they can have poor overall health as well — so, there’s the costs associated to our overall healthcare system there. It’s harder to find a good-paying job when you’re missing front teeth, so there’s potential for added cost to social programs as well, and there’s also elements of: what do you do when you can’t afford dental pain? What a lot of people end up doing is going to the doctor’s office or emergency departments for dental pain; they only end up receiving an antibiotic and pain medication, which is really just a band-aid solution that leaves them still needing to see a dentist to either have the tooth removed or to have a root canal done. This is a really big problem. So, if we look at a study done in 2014 in Ontario, they found that doctor’s offices were visited 220,000 times, and emergency departments 67,000 times, by patients seeking treatment for dental pain. Those are huge numbers, and it results in a minimum spending of $38,000,000 per year. This is a very downstream approach that results from our private dental care system; this money is not well spent. In a more sensible world, I think that that money should be going directly towards dental care.

Thomas: We should recognize that, from an economic perspective, this is all waste that we, as a society, bear and pay in our taxes: sending people to emergency departments for issues that the ED can’t treat, sending them back with, more often than not, just a written pain prescription. And, if that prescription becomes covered by the public system or whatever, that’s more wasteful resources that we’re allocating to something that doesn’t treat the root cause of the issue, if you’ll pardon the pun.

Patrick: Thinking historically here, when medicare was implemented in Saskatchewan in 1962, prior to that happening and prior to it being adopted on a national scale, we saw the medical establishment go into open revolt against the government that wanted to bring in these progressive reforms. Saskatchewan’s doctors opposed Tommy Douglas’ CCF government in the preceding election, and then in 1962 they waged a very nasty campaign against medicare which included doctors going on strike. What is your sense of the opposition among dentists to including universal dental care under medicare? Do you think we would see dentists go on strike, or do other sorts of things, to oppose such a move?

Brandon: I think that’s a great question. I do think that, from my experience, there’s been a lot of mixed results from dentists. Some are very supportive. Some, to be honest, really don’t see this as their problem; they come from a socioeconomic class where they don’t struggle accessing dental care. And some people just care about their bottom line, so they will see this in the same way that physicians saw the implementation of medicare. But I think that this is something that our group, with the Coalition for Dentalcare, where we are working with a lot of other health care providers, researchers, and the public and the dental community who are interested in this subject to try to raise the profile of an issue like this, to try to overcome those barriers, because I do think, from the organized dentistry, there will be opposition as there was opposition to bold public programs in the past. Keeping in mind that, when the implementation of medicare was happening, there was musing about including dental care in our universal healthcare system. There was excuses made by the dental community as to why that couldn’t happen, and many of those excuses, in my opinion, were nonsense; they were not good reasons as to why dental care shouldn’t be included in our universal healthcare system. But, because physicians were in the crosshairs as far as that battle for medicare, dentistry, they were able to stay out of those crosshairs, and we’re still living with the consequences of that today.

Thomas: I think Brandon alluded to this from an earlier question — one of the issues with, when you have public insurance, the existing smattering of plans that are out there, is that these plans don’t compensate the dentists to the full extent that they would be compensated on the private market. I think that this is creating a sense of skepticism in the dental community about government’s commitment and role that they would play in providing dental care if it was expanded. There’s a survey that was done out of the University of Toronto — in 2009, I want to say — and it looked at dentists’ opinions on public insurance and public involvement in dentistry, and that’s the sense that they gathered. There seemed to be a skepticism there. We also saw that about 33% of dentists in Canada made the decision to reduce the number of public insurance patients they had in their practice which, frankly, to me, is insulting and abhorrent, but it is a business decision because, if they aren’t reimbursing you at the rate that you need and you have other patients coming to you and that takes up your time but they’re willing to pay you more — homo economicus, the rational actor — obviously, you’re going to choose the one that will pay more. That’s the free market structure we have in dentistry and, frankly, that’s what we don’t like in medicare. But I think that, if government can show that it takes dental care seriously and turn to real negotiations with dentists about what kind of fee schedules they’d reimburse at and fair rates, we might see that improve. Look at today — look at what we’re having happen in Alberta. When the UCP put out Policy 11, which suggested moving healthcare into a two-tiered state, the biggest uproar came from a lot of physicians working in the public system. You see that switch, politically, on sides. I think it will be a rough road to implementation but, once dentists see that government takes this seriously (and the government does, in fact, take it seriously), I think we’ll be well on our way.

Brandon: I think something to add to what you’re saying, as well, Tom, is that there’s the dental community’s opposition, but we also have to keep in mind that there’s many other financial interests at play here, whether that be private insurance companies who don’t want to lose any profits. There’s a trend in dentistry of corporate dentistry — so, big financial investment firms buying up a bunch of dental practices and using that to generate profits. There’s many other industries as far as dental equipment and supplies which, under a universal system, we could buy them in bulk and lower supply costs significantly. There’s a lot of other financial other interests, as well, that we’re going to face opposition from, but it’s important that we stress that this opposition is something that is directly in conflict with public interests because we can lower the costs of dental care in some ways without lowering quality.

Karen: So, Brandon, you’ve advocated for breaking up the monopoly on dental care that dentists have in Canada by making dental therapists mainstream in Canada. Could you explain what a dental therapist is, and how their duties might be different from the dental experts that we’re mostly familiar with — hygienists and dentists?

Brandon: Sure. So, dental therapists are basically mid-level dental providers that can perform simple procedures like fillings, simple extractions, cleanings — basic procedures at a fraction of the cost that a dentist would charge. This is a very similar relationship between a physician and a nurse practitioner; so, a nurse practitioner isn’t going to be doing major surgery, but they could be placing stitches at a fraction of the cost of what a dentist can do. When we’re looking at this on a system-wide basis, we can really lower costs by utilizing these mid-level providers, especially in dentistry because a lot of the procedures — say, like fillings — are just routine things that, using these mid-level providers, we can save a lot of money. We actually had a public dental plan in Saskatchewan in the 1970s and ‘80s that used these dental therapists in school-based dental clinics, and it was wildly successful. The mid-level providers worked in schools to communities that, before, didn’t have any dental provider nearby, so a lot of people, before the program, would’ve had to drive an hour and a half, two hours, to the nearest dentist. You can imagine how difficult that is for families to take time off work and everything like that, so these school-based clinics were very accessible, and the salaried dental therapists were integral to making these procedures accessible and, also, affordable. Taxpayers didn’t have to pay out an arm and leg because they weren’t paying, for example, $250 for a filling; because they used these mid-level providers on a salaried basis, the cost per unit of delivery for these services was significantly less. Over time, with this program, children needed, on average, half as many fillings and extractions as they did before the program, so you can even see, over the length of the program, how much health your children were getting because of the focus on prevention and early treatment. I think, as well, these mid-level providers — if we’re looking in the 21st century, there’s a huge area in which we can use them, and I don’t think they should be confined just to the school setting. The first step we’d need is to actually have a new dental therapy training program in Canada. The Saskatchewan program was privatized in the 1980s and, later, in — I think it was — 2009, the last dental therapy training program was closed, so it’s a field that is decreasing in size in Canada unless we open a new program. But, if we do open a new program for dental therapy, the options are very exciting, in my mind. We could have dental therapists working in community-based clinics in primary health centres as well as places like schools that I’ve mentioned, but also other other places like long-term care facilities, prisons, and many other areas, because the traditional private practice model has left many communities without dental providers, particularly rural and Indigenous communities, and the public ownership of dental clinics and hiring of dental therapists to work in them is really a very effective way to make sure that these communities not only have dental insurance but actually have a dental provider nearby to provide services for them.

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Kate: Getting to maybe one of the more contentious issue — or, at least, one of the questions that I think a lot of Canadians will have when we talk about including dental care in our public medicare system — who would pay for expanding dental care, and how could such a program be funded? It would obviously mean much more people receiving care, so more dental work would be done, and there certainly would be a range of health and economic benefits that would occur as a result., but I’m wondering how you would recommend an expanded dental care program be financed? And are there any proposals without co-pays or premiums?

Thomas: This is something that I did research on recently and published two papers with the School of Public Policy (which are available on their website, policyschool.ca — you can download them for free). The two papers that I did, I was trying to figure out exactly what you asked — what could a publicly-financed universal dental care look like, and how much would it actually cost? Because, to date, we’ve had whispers of this — even, as brandon mentioned, going as far back to the birth of medicare — but, really, no cost estimate, and policymakers across the country need that. So, we’ll start with the first side of the equation, which is cost, and the second side is obviously paying for the cost revenue. I looked at 14 different treatment categories of dentistry, which span all the way from providing scaling, preventative, and recall exams, things like that — x-rays — all the way up to root canals, dentures, and even some orthodontic work. The cost that comes back through our econometric model, which I’ll save listeners the painstaking, boring details, it comes back to over $20,000,000,000 nationally. But that’s just the gross clinical cost. As you said, that would be a situation in which we had no co-payment, no premiums, nothing of that. But then we also have to factor in — there’s administrative costs which also get added in; that adds it up a bit. And there’s also the fact that this universal program would actually be replacing existing programs, and if it’s universal, meaning everybody’s covered, it replaces everybody that’s on a private insurance plan, which includes public sector employees. Public sector employees — full-time ones — across all layers of government in Canada more often get dental benefits, but they’re brokered through a private brokerage, and that’s money that we pay for through our taxes. Our estimates total that up to about $6,000,000,000 in 2019. That’s just for public sector workers. So, you’d be replacing that. You’d be replacing the about $1,000,000,000 that we spent in 2019 on those public plans. So, just think about that for a sec — $1,000,000,000 is spent on, as we said, people who are lower socioeconomic status who need the higher burden of oral health disease. We only spend $1,000,000,000, but to cover the whole system, we need to ramp this up to close to $20,000,000,000, clinically. And there are terms of clinical costs. So, you’re right — there would be expected big increase in the total number of Canadians using dentistry and, perhaps, the frequency in a given year by which they utilize dentistry but, as we said before, this has benefits that are preventative on the rest of the health system, as well. The rest of my work comes into looking at alternatives, and the alternative that I looked at was: what if you just covered this for people who don’t have private insurance? So, fill in that gap — because, as I said at the beginning of this — I don’t know if I put a number to it, but it’s about 33% of Canadians who don’t have insurance for dental care; any insurance, public or private. So, it’s a pretty significant gap. How much would it cost to fill that? And it’s close to about $14,000,000,000, so obviously the gross clinical cost is less because you’re covering less people. Now, where it gets a little interesting is when we talk about this idea of co-payment and premiums. I want to emphasize, from an economist’s perspective — I know that, in the healthcare system, we don’t do co-payment, less and less provinces are doing premiums — but I want to emphasize that it is kind of important to have these measures built in because you don’t want to necessarily have completely frivolous use of public-covered dental services. You want people to make sure that they are still brushing their teeth, still taking their oral health seriously. And, from a behavioural economics perspective, we know that adding in even marginal co-payments does change behaviour, and studies do show it does change behaviour towards good oral health practices, good overall health practices to be preventative. The theory — and this is a theory, it’s unpublished, I heard this from an econ prof once who suggested that those fail videos on YouTube where people are, like, breaking their necks [inaudible] and everything — those tend to occur more often in countries that have robust healthcare systems [laughs] because the financial burden is on the public system, it’s not on them. But, if you add co-payment, people start to make different choices. That’s just a theory; I don’t really subscribe to that religiously, but co-payments and premiums, I do feel, are very important. I feel that they’re important as long as they’re tiered to your ability to pay them. So, in my paper, we tiered them based on your income and exempted a lot of lower-income individuals, like below a household income of $40,000-$20,000, that kind of thing, and below. So, really, you would be having higher income people paying in the lion’s share of direct out of pocket into these programs; in that sense, it transfers financial risk from low-risk individuals to higher-risk individuals. In that sense, higher-income people subsidize lower-income poeple more directly, and that’s very important to have. So what we do is: we created a structure of co-payments and premiums, and we applied them to both programs, and here’s what we found — when they’re applied to both programs, the universal dental care program, at the net, costs less than the net cost of just providing dental insurance to those without insurance. The main drive behind this is because, under that latter program, public employees are no longer to be on it (because they have dental insurance through a private provider), and most of the people in that insurance pool you’re covering are poorer individuals who are exempt from co-payment or pay less of a proportion. So, putting everyone in the same basket of payment — that is probably the most efficient way that we could go forward with this, holding those two things equal. Now, in terms of actually rolling it out, the option of just providing insurance to those who don’t have it is probably the easiest way to go forward because you’re not necessarily stepping on toes of private industry, but you still need to make sure that you’re, as I said before, compensating dentists fairly so they don’t just, again, choose not to take people on the public programs. To answer the other part of your question, or the other part of the equation, how do we pay for it? Because there’s still a net cost — $6,000,000,000 is the net cost of national, universal dental care — how do we pay for that? Really quickly, I’d like to see us raise tax revenue, potentially, that could help deter unhealthy behaviour such as the sin taxes on sugary, sweetened beverages. I can go into more detail on that later, but we know that high consumption of sugary beverages causes oral health disease, or is linked to it, so taxing that away may be a way to contain costs in universal dental care as well as pay for them using the tax revenue.

Brandon: I think — to add something to what you’re saying there, Tom — I think it’s really important to stress, when we’re talking about paying for universal dental care, that we can actually shift the burden of cost onto the wealthy because you can structure taxes in such a way that — say the average person now is paying $600, $700 per person per year for dental care through their private insurance and out of pocket payments. When you structure the tax system in such a way, you can structure it so that average working-class people might only be paying $300, $400 whereas somebody who makes a couple million dollars a year is going to be paying a lot more.

Kate: I really appreciate you bringing that up, Brandon, because, from my perspective on co-pays and premiums — ultimately I do disagree with Tom’s perspective here — taxation is a much better way to make sure that the wealthy are subsidizing a public service like universal dental care for the rest of us rather than a tiered co-pay system. And the reason I do say that is because ultimately, at the end of the day, I would rather have a small minority of people take advantage of universal dental care through frivolous uses than have people not be able to access dental care because of the financial burden that it places on them, or even the administrative difficulties that something like a co-pay or a premium system places onto people; not to mention that I think a co-pay or a premium system adds an administrative burden to any kind of universal system and that removing that burden of clerical and of administration not only makes the program easier to administer, but it also makes it easier to defend politically, both when you are implementing it and, with universal medicare, when you are defending it from the decades of attacks that have happened to it across the country.

Thomas: Sorry, just to rebut really quickly —

Kate: Of course!

Thomas: — honestly, I like this discussion. I like the points you raise; again, please disagree with anything I say. Honestly, the only way that we get good public policy is if we have debate, frankly. Just to your point about — I’m fine with a small share of the population having frivolous use. When you think about it, the small share that I’m referring to is the lowest on the income structure; they’re exempt from it, so the behavioural effects of co-pays, premiums, that doesn’t touch those individuals. An argument I’ve had with a few other health economists is, “Oh, no, well, the poor will be going off and getting a bunch of denture work and orthodontic work,” and my exact response to that was similar to yours, which is, yes, good, because they’re the ones that have the highest burden of it; it’s not actually frivolous because, when you’re lower-income and lower socioeconomic status, you have a higher risk for dental issues. Like we said, there’s that cycle of poverty — if you don’t have good teeth, you’re not going to get a good job, so I would like to see those individuals being able to take advantage of orthodontic work and things like that. It’s when you get further up the chain. If you have the household ability to pay directly, then I think you’re going to get a lot of arguments from both economists but also from people on the libertarian side of the spectrum who would say you should be able to do it yourself — if you have the means to pay, do it. I strictly argue from an economic perspective — you’re trying to transfer financial risk between pools. And you’re right — the tax system does do this, but salience matters. What I mean by that is that it’s kind of like when you look at your bill at a restaurant and you see the tax listed out, or you see it on the menu. It changes how you think as a consumer. I know that sounds a little weird because I’m calling you consumers, not patients, but from an econ perspective that’s what they are. It does cause you to think about this. And the way we tier it in the paper is: we really emphasize low, low levels of co-payment on preventative measures and routine checkups so, that way, people are going to the dentist more often. And that way, too, it undercuts the private plans, because they don’t tier based on your income, which is not fair. [laughs] That’s my rebut there.

Brandon: I think something to add to that, Tom, as well — I think, in theory, that adding the tiered co-payment system can have benefits. One concern I have, politically, though, is that, once you open the door for those out-of-pocket payments, it’s much easier for, say, a conservative down the road, in time of austerity, to make that co-payment or that out-of-pocket payment apply to broader swaths of the population in order to save government spending.

Thomas: And I take that point, too; to be honest, there’s a side of me that would say that might be necessary if that’s the choice. We have to think about overall healthcare spending as it is right now. In Alberta alone, income tax — just personal income tax — does not cover the cost of the healthcare system. So — and I know we have other tax revenue sources — as I’m saying earlier, we need to think about other new ones if we want to talk about expanding the healthcare system. Yeah, and also, to a point that was brought up before about “it’s an administrative burden.” I think that’s a very fair point because currently, in Canada, we don’t have an auto-file tax system, so how do we link the — and now I sound like I’m arguing with myself, but I’m full disclosure on it. We don’t have an auto-file tax system, so how do we link your income from your last notice of assessment to your healthcare number? The data exists, it’s possible — we know from other European countries that have very advanced e-government structures — that we can be done, and the Trudeau Liberals have suggested in the last speech from the throne they want to move to that — so, when we talk about oral healthcare, that’s a big piece of the puzzle we’re missing. As I mentioned before, you can’t get on the existing programs unless you can prove you’re poor. Unless we fix that hurdle, then exactly — as I’ve proposed in this paper about co-payments and premiums — it can’t actually be administered effectively.

Kate: And I’m happy to argue for an auto-file tax system as well — it’s something that I believe should exist because of the administrative burden that it places on poor and working-class people — but ultimately, at the end of the day, I do think co-pays and premiums are antithetical to a vision of universal dental care, and I think one of the reasons that universal programs like our universal medicare system are so strong is because they create a much larger constituency than a program that is tiered in any way. One of the main political issues I foresee with a program that includes co-pays and premiums is that it could be structured in such a way that people will begin to think of public dental care as something that is for poor people, or that is for certain segments of the population, rather than something that is universally held and universally defended. So, I think, when you have a program that’s universal, you create a larger political constituency that can be mobilized to defend it in the future, and I think that’s very important for not only defending the program itself, but also for how building up a stronger welfare state fundamentally restructures our society in a way that I believe is positive.

Thomas: Absolutely. I think it’s more of an argument I would agree with when you’re thinking of the choice between those two models I put forward: the two ideas of universal dental care or dental care just for the people who don’t have insurance, because that’s a lower pool and, as you said, there’s less agency in the public, there’s less buy-in from people when you’re like “That’s just for the poor,” and that’s why, in those papers, I tend to argue for the universal, single basket, everyone in the same pool because we do have agency. I don’t necessarily — I’m not aware of any studies or political science studies to suggest that being in one pool and having one person pay a premium while another person not necessarily takes away that agency from higher-income people being involved and keeping their buy-in to the system that they have, because that certainly was not the case that we saw with MSP premiums in British Columbia or even when we had health premiums here in Alberta. Public policy is hard because it always involves choices, and I think you raised some very interesting trade-offs that premiums and co-payments have that are maybe more political in nature than, say, economic.

Brandon: I was just going to say, Tom — I feel like that’s something I very much appreciated, reading your papers, was that I feel like very few academics make those bold stances and say “We should switch towards a universal system.” From my experience, many have been much more comfortable saying “Maybe we should tinker around the edge here or there,” but making the jump towards having a universal system, I think, is a huge step in the right direction because, when we have a system where someone can get paid $100 for doing a filling for one person and $50 for doing a filling for another person, we create a fast lane for the people who have that higher amount and a slow lane for the people who don’t. At its core, that universal dental care system is a huge step in the right direction, to fix that and create a more equitable dental care system.

Thomas: A hundred percent, and we have a whole Supreme Court decision in BC that explained why we didn’t want that in medicare, that you could have a fast line for people who can pay for their day surgeries versus everybody else that can’t.

Patrick: One interesting thing that came up, Brandon, while you were talking, is salary-based dental therapists. I assume the calculations, Tom, that you’re doing are like other medicare things and they’re done by procedure rather than salaried, so I think it would be interesting to open up the question: what would a salaried form of dental care, something along the lines of the UK’s NHS — although the UK’s NHS has co-pays for dental care — but what a salary-based dental care would look like. But then, thinking more broadly about some of these things, one of the other things we see is that Alberta has a dental fee guide which the Alberta Dental Association releases, which is supposed to act as a general, non-binding guide on the costs for services. Prices in Alberta tend to be higher than, say, in BC — 26% to 32% higher, for example — so what do you think explains the price differences that exist already, and then how do we go about dealing with those if we’re going to make a publicly-funded system?

Brandon: I think something to add to what you’re saying is: I think it’s very interesting to see how our private dental care system works. So, Alberta’s obviously had financial financial booms with the oil industry and people who make make a lot of money, and dentists have chose, instead of using this as an opportunity to have a larger segment of the population accessing these services, they saw it as an opportunity to raise their fees. And this is something that you can do when you’re in a private dental care system because there’s no tug of war, really, between dentists and the public trying to figure out what a reasonable fee is — there’s just the tugging by the dentists, and they’re tugging it in a higher direction, and we don’t have that collective force acting on behalf of the public tugging in the other direction. That’s something that, under a universal dental care system, we have the ability to move in the other direction; we can actually have the conversation, “How much should a filling cost?” And the program that we are proposing under the Coalition for Dental Care is a universal dental care system that follows three main principles. One of them is universal dental insurance, which, as we’ve discussed, that one results in — most dental offices that operate under private practice would still operate, but they would be paid by the government rather than private insurance, but along with this, we would also create a publicly-owned dental sector, which creates clinics in many poor and marginalized that’s been neglected by the private practice fee-for-service model. So, what we propose is that these publicly-owned clinics be set up in, say, poor, rural, and Indigenous communities, but also in long-term care facilities, schools — I’m sure there’s other areas, as well, that I can’t think of off the top of my head. This is where the salaried dental therapists should work. That public salaried approach is very effective, especially when you’re delivering services to certain communities, because you can imagine — if you were doing a filling, say on a child with autism, it’s going to take a lot more time and energy than doing on a filling on a child who cooperates well, and it’s going to take a lot less time for that child, as well. So, if you’re working on a fee-for-service model, you’re really disincentivizing people from working on, say, people with disabilities who it takes, on average, more time for a procedure.

Thomas: Yeah. I just want to jump in to mention — the papers I wrote were before I was aware of this proposal, so it’s not costing out, specifically, Brandon’s proposal, although I really like it, and I really like the idea of using mid-level providers, using more public space, to deliver in rural, remote communities. These might be additional costs, but they might also be offset based on using mid-level providers, so they may not change the overall costing figures of a universal insurance system by too much. The other area that I do research work in has been physician compensation in Alberta, and we’ve seen how we’ve been very locked into fee-for-service. And you’re right — my costing analysis was on the assumption of fee-for-service. There was a line in the second paper I wrote, towards the end, that suggested, among our other recommendations, we pursue things like capitation rates or salaries because these tend to produce better allocation of dental resources and dental services and utilization overall in the system. If we’re starting something from scratch — which is the title of one of the papers — we’re starting a new universal dental care system, let’s try and get everything right. [laughs] Let’s do the things that our current health system has really been floundering with, which is, for one thing, how we remunerate physicians, and really try and leverage that evidence that we know about how payment mechanisms in healthcare really affect overall care quality and outcomes, apply that to dentistry. That’s just my addition there.

Brandon: I think something to add to what you’re saying, Tom, as well, is that our decision with the Coalition of Dental Care to go with that joint private practice and public dental clinic model is, to some extent, a tactical decision based on what we feel we can hoepfully achieve in our society. And what we see is: dentists, by and large, want to work on the private practice, fee-for-service model, and we see ourselves as needing to build the institutions, build the bridges, within the dental community to educate people, to really start to build the will where dentists are going to want to work in that sector, because what we see a lot of dentists do is: they pivot away from doing basic dental care because they have the option of doing luxury and cosmetic procedures, so instead of them setting up a clinic in, say, a rural or poor neighbourhood that really needs dental care, they tend to set up in wealthy areas of cities where they can do very high-revenue procedures that are very luxury and cosmetic rather than doing basic dental care. So we made the tactical decision that a universal dental plan, as described, providing everyone with insurance will, on the one hand, drive dentists into those private neighbourhoods and hopefully set up clinics, but also the public sector will help fill in the gaps that dentists aren’t servicing, so those public clinics can go, say, to rural Indigenous communities, long-term care facilities, places like that, in a more organized fashion.

Thomas: A hundred percent. Because I think what Brandon’s really alluding to is these other dimensions of access. When we talk about what is improving access to oral healthcare, that’s a multidimensional thing. We’ve talked about financial access a lot on this podcast so far — who pays the bill, by how much — we’ve debated a little bit a bout the types of financing, and we’ve also touched on this other aspect, which is physical access — finding a dentist near you, let alone finding a dentist near you willing to take you on as a patient. And then there’s also the bureaucratic access that we talked about before — if it’s just programs for the poor, how do you prove you’re poor, how do you prove you’re eligible. So, all of these put together are really key considerations that the government’s really going to have to think long and hard about.

Kate: Brandon and Thomas, thank you so much for coming on our podcast and giving us a comprehensive overview of some of your work and advocacy around dental care in Canada. If people are interested in finding out more about you or the work you do, where should they go?

Brandon: They can find us at Coalition for Dental Care on Facebook, Instagram, Twitter. Please message us if you’re interested and want to get involved, or just follow us to see more events and information on the subject.

Thomas: Yeah, and you can head over tot he School of Public Policy website, policyschool.ca, and you can find those publications that I worked on there. As well, you can follow me on Twitter — @TomLangeYYC.

Kate: Amazing. Yeah. Once again, thanks so much for joining us. I think this episode turned out great.

Thomas: Thank you.

Brandon: Thanks for having us.

Thomas: Thanks for much for the debate, too. I really liked it.


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Kate: If you liked today’s episode, you should check out the Harbinger Media Network, featuring shows like 49th Parahell, where ideological influencer and Twitter titan Rob Rousseau explores the hellish nightmare world of modern reality together. Find out more about the Harbinger Media Network and the entire cross-country line of podcasts at harbingermedianetwork.com.

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